17.
Keenen MA, Perry J, Jordan C.
Factors affecting balance and ambulation following stroke.
Clin Orthop 1984;182:165, 171. 18.
Pinzur MS, Graham G, Osterman H.
Psychological testing in amputation rehabilitation.
Clin Orthop 1988;229:236, 240. 19.
Pinzur MS.
Current concepts: amputation surgery in peripheral vascular disease.
Instr Course Lect 1997;46:501, 509. 20.
Pinzur MS, Sage R, Schwaegler P.
Ray resection in the dysvascular foot.
Clin Orthop 1984;191:232, 234. 21.
Pinzur MS, Gold J, Schwartz D, Gross N.
Energy demands for walking in dysvascular amputees as related to the level of amputation.
Orthopaedics 1992;15:1033, 1037. 22.
Pinzur MS, Wolf B, Havey RM.
Walking pattern of midfoot and ankle disarticulation amputees.
Foot Ankle Int 1997;18:635, 638. 23.
Smith DG, Sangeorzan BJ, Hansen ST, Burgess EM.
Achilles tendon tenodesis to prevent heel pad migration in the Syme’s amputation.
Foot Ankle 1994;15:14, 17.
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27 Rehabilitation of the Amputee with Diabetes E.R.E. Van Ross and T. Carlsson
INTRODUCTION In previous editions of this book, this chapter was entitled ‘Rehabilitation After Amputation’.
However, the authors recognise this title to be misleading.
The term ‘diabetic foot’ implies a chronic impairment with irreversible pathology.
The preceding chapters written by physi- cians, podiatrist, nurses and surgeons really do come within the definition of ‘rehabilitation’.
Amputation is but an episode within a diabetes management process that began many years previously.
Also, amputee rehabilitation begins prior to amputation and not, as is traditionally viewed, after the completion of surgical limb ablation.
Rehabilitation is the process of obtain- ing optimal function despite residual disability.1 Physical, sensory and mental capacities are restored or developed in people with disabling conditions, and so rehabilitation may be viewed as an enabling process.
Comprehensive rehabilitation should address all of the following issues2
r the damaged system or part (the amputation stump); r other body systems (cardiovascular, respiratory system, also the contralateral limb); r psychological attitudes; r immediate factors affecting the material environment, e.g. clothes, prosthesis, etc.; r the near environment, e.g. housing, stairs; r distant environment, e.g. access to shops, social outlets, etc.; r social support networks.
Much too often, we hear patients say ‘I wish they had done the amputation earlier’. This simple admission by the patient should provoke all professionals to review their clinical practice and decision making. When it is advised, amputation should be a positive treatment offered at the appropriate time. This is by no means an argument for increased or hasty amputation surgery but rather a statement that treatment is directed towards the interests of the patient,
The Foot in Diabetes, 4th Edition. Edited by Andrew J.M. Boulton, Peter R. Cavanagh and Gerry Rayman. C 2006 John Wiley & Sons, Ltd. ISBN: 0-470-01504-7
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324 REHABILITATION OF THE AMPUTEE WITH DIABETES
rather than the foot lesion alone.
Extended attempts to save the foot, whether successful or not, may be at the expense of general deconditioning, joint contractures, loss of motivation and severely reduced mobility.
Clinical decision making is enhanced by excellent communication and even crossover between the team caring for the foot lesion and the amputee rehabilitation team.
Professionals should provide complete information to patients, allowing them to face potentially unpalatable situations with calmness and dignity, knowing they have made the best decision for themselves.
THE AMPUTEE POPULATION About 1 in 15 foot ulcers result in amputation.3 It is estimated that only 50% of all people undergoing lower extremity amputation are referred to the amputee rehabilitation team for fitting of a prosthesis or appliance.
Those not referred to the amputee rehabilitation team either have a ‘minor’ amputation of a toe, or part of a toe, and continue to be managed by the foot team, or are considered to be so severely impaired that they would not benefit from rehabilitation.
Patients referred to the amputee rehabilitation team have usually undergone a ‘major’ am- putation at the transmetatarsal level or at a more proximal site.
Figures for the United Kingdom show a 35% increase in new dysvascular amputees referred to artificial limb centres over the last 8 years4 with the majority of amputations performed at the transtibial or the transfemoral level.
Surgical teams are aware that the more distal the amputation the better the outcome for the amputee.
Some recent studies indicate that an increasing percentage of partial foot amputations are now being performed.5
APPROACHING AMPUTATION Rehabilitation must be perceived as a continuum, with a seamless transition from the team providing foot care to the amputee rehabilitation team.
The multidisciplinary amputee rehabil- itation team is now accepted as the best working model for the delivery of care.6 At the centre of the team is the patient, his/her carers and family.
The other members of the team include a rehabilitation physician, prosthetist, nurse, physiotherapist and occupational therapist, clinical psychologist/counsellor and, importantly, a podiatrist who links in with the foot care team.
This close-knit team must have access to clinicians from other disciplines in the medical and surgical specialities besides primary care, community rehabilitation, vocational rehabilitation, benefits agencies, etc.
The Pre-amputation Phase The pre-amputation phase begins as soon as amputation is contemplated.
It includes a full medical, psychological, environmental and social evaluation of the patients and their home circumstances.
Time must be spent to explain the reasons for amputation together with the potential advantages and disadvantages and the likely functional outcome.
In our practice, whenever possible, the patient is invited to the artificial limb centre to meet the rehabilitation team, see the range of available prosthetic hardware and get a clear idea of the planned reha- bilitation process.
Counselling the patient and the family and introducing them to an amputee who has already been through the experience can be an invaluable preparation.
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GENERAL PRINCIPLES APPLICABLE TO AMPUTATION SURGERY 325
The psychologist should assess the person’s own psychological perceptions of his/her med- ical condition and personal health beliefs. The assessment can highlight the patient’s hopes, motivation and dissatisfaction and indeed direct extra attention to vulnerable personalities requiring additional support in the post-surgical phase. The key to pre-amputation planning is to choose the correct level of amputation to be performed at the most propitious time, on a well-informed patient.
The Surgical Phase The aim of amputation surgery is to produce a residual limb (stump) that is functional and will control a prosthesis. Amputation surgery is a positive treatment and should not be viewed by surgeons as a failure of surgical practice, to be performed as the unsterile last case on the operating list by the most junior surgeon. Surgeons should be proficient with modern techniques and knowledgeable of available prosthetic hardware.
GENERAL PRINCIPLES APPLICABLE TO AMPUTATION SURGERY
Skin The scar should be healed and not adherent to underlying bone.
Scar placement is almost immaterial , modern socket materials can cope with fragile scars in any position.
Full-thickness and partial-thickness skin grafts should be used only when absolutely essential and not located over bony prominences.
Skin flaps must be sutured at the correct tension if they are to remain healthy and pressure tolerant.
Skin clips used for closure inhibit early mobilisation on a pre- prosthetic device.
Instead, nylon sutures supplemented with adhesive skin strips work well.
Muscle Muscle flaps should be stabilised by reattachment to bone (myodesis) or attached to their opposing muscle (agonist to antagonist myoplasty). Bulky myocutaneous flaps are undesirable, and the more vulnerable ischaemic muscle should be excised.
Nerves Neuroma formation is inevitable after amputation. Large and obvious nerves should be placed under gentle traction and cleanly divided in order to allow the ends to retract into underlying muscle. Coagulation, diathermy and cold blocks of nerves are not routinely used.
Blood Vessels It is a fallacy to believe that the absence of bleeding is an indication for higher level of amputation.7 Wound healing is more subtle and depends on the microcirculation. Arteries should be suture ligated separately and away from veins in order to avoid fistula formation.
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326 REHABILITATION OF THE AMPUTEE WITH DIABETES
Bones Preparation of the bone end is of the greatest importance. The bone must be cut to the correct length and the distal edges bevelled and then smoothed, in order to avoid prominent sharp bony edges under the skin.
Dressings A wool bandage followed by a crepe over bandage is the commonest method of dressing following surgery and, in general, these dressings work well. For the below-knee amputation in particular, stump bandaging is generally unsatisfactory and there is often evidence of iatrogenic oedema caused through the bandage acting as a tourniquet. A removable rigid plaster of Paris cast dressing8 is advocated for control of oedema and protection of the wound or, if impractical, a commercial stump shrinker is used.